China’s National Healthcare Security Administration (NHSA) has released the “Regulations on the Management of Medical Insurance Payment Qualifications for Personnel in Medical Security Designated Medical Institutions.” These regulations aim to enhance the rational use of medical insurance funds and maintain fund security through improved management efforts. The document came into effect on January 1, 2025.
Regulatory Requirements
According to the new regulations, medical insurance agencies are required to sign medical security service agreements with medical institutions in accordance with established guidelines. This includes strengthening the management of designated medical institution agreements and implementing requirements for the management of medical insurance payment qualifications for relevant personnel. Once the service agreement is signed, relevant personnel practicing (employed) in designated medical institutions can obtain medical insurance payment qualifications as per regulations. They can then provide medical services to insured persons and be included in the scope of medical insurance supervision.
Institutional Responsibilities
Designated medical institutions are required to complete the registration and filing of relevant personnel, service commitments, status maintenance, and medical insurance expense declarations as required. The management of medical insurance payment qualifications for relevant personnel can be linked to incentive and constraint management systems, such as annual assessments and internal notifications. Medical security agencies are expected to perform well in scoring management, information verification, and strengthen the management of medical insurance fund audits and settlements.
Scoring Management System
The document introduces a scoring management system to oversee the relevant responsible personnel involved in the use of medical insurance funds in designated medical institutions. Scoring is based on administrative penalties and agreement processing, and is accumulated and calculated within a calendar year. If the cumulative score of the relevant responsible personnel does not reach 9 points, the medical insurance agency shall report the score status to the designated medical institution where the relevant responsible personnel are located. If the cumulative score reaches 9 points but does not reach 12 points, the relevant personnel’s eligibility for medical insurance payment will be suspended for 1-6 months, depending on the severity of the situation. Those who score 12 points will have their medical insurance payment eligibility terminated. Individuals who accumulate 12 points shall not be allowed to register and file again within one year from the date of termination. For those who accumulate 12 points at once, they are not allowed to register and file again within 3 years from the date of termination.
Future Prospects
These new regulations represent a significant step by the NHSA to ensure the efficient and secure use of medical insurance funds. By implementing a robust management system and a clear scoring mechanism, the NHSA aims to enhance the transparency and accountability of medical insurance payments, ultimately benefiting both healthcare providers and insured individuals.-Fineline Info & Tech
